Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack From the Stroke Council of the AHA

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Guidelines for Prevention of Stroke in Patients
with Ischemic Stroke or Transient Ischemic
AttackFrom the Stroke Council of the AHA

• Ralph L Sacco, Chair Robert Adams, Vice-Chair
• Greg Albers, Mark J Alberts, Oscar Benavente,
  Karen Furie, Larry B Goldstein, Philip Gorelick,
  Jonathan Halperin, Robert Harbaugh, S Claiborne
  Johnston, Irene Katzan, Margaret Kelly-Hayes,
  Edgar J Kenton, Michael Marks, Lee H Schwamm,
  Thomas Tomsick

Sacco RL et al. Stroke 200637(2)577.
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AHA Classes and Levels of Evidence

• Class I Agreement the treatment is useful and
  effective
• Class II Conflicting evidence and/or a divergence
  of opinion about the usefulness/efficacy of a
  treatment.
• Class IIa Weight of evidence is in favor of the
  treatment.
• Class IIb Usefulness/efficacy is less well
  established by evidence
• Class III Evidence and/or general agreement that
  the treatment is not useful/effective and in
  some cases may be harmful.
• Levels of Evidence
• A Data derived from multiple randomized trials.
• B Data derived from a single randomized trial or
  nonrandomized studies.
• C Consensus opinion of experts.

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Blood Pressure ControlASA 2006 Secondary Stroke
Recommendations

• Antihypertensives are recommended beyond the
  hyperacute period (Class I, Evidence A).
• Benefit for those with w/o HTN (Class IIa,
  Evidence B)
• Target BP level and reduction are uncertain, but
  normal BP levels are lt120/80 by JNC-7 (Class
  IIa, Evidence B).
• Lifestyle modifications have been associated with
  BP reductions and should be included (Class IIb,
  Evidence C).
• Optimal drug regimen uncertain data support
  diuretics and the combination of diuretics and an
  ACEI (Class I, Evidence A).

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Diabetes ASA 2006 Secondary Stroke
Recommendations

• More rigorous control of HTN and dyslipidemia
  should be considered in patients with DM.
• BP targets of 130/80 mm Hg (Class IIa, Evidence
  B). ACEIs and ARBs are recommended as
  first-choice medications for patients with DM
  (Class I, Evidence A).
• Glucose control is recommended to near
  normoglycemic levels to reduce microvascular
  complications (Class I, Evidence A) and possibly
  macrovascular complications.
• Hemoglobin A1c goal lt7 (Class IIa, Evidence B).

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Cholesterol Control ASA 2006 Secondary Stroke
Recommendations

• Those with elevated chol, CHD, or evidence of an
  atherosclerotic origin should be managed
  according to NCEP III (Class I, Evidence A).
• Statins are recommended with target LDL-C of lt100
  mg/dL and lt70 mg/dL for the very highrisk (Class
  I, Evidence A).
• Those with no pre-existing indications for
  statins (nl chol levels, no CHD, or no
  atherosclerosis), are reasonable to consider for
  statins to reduce the risk of vascular events
  (Class IIa, Evidence B).

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Carotid Endarterectomy ASA 2006 Secondary Stroke
Recommendations

• Ipsilateral severe (70 to 99) carotid stenosis,
  CEA is recommended (Class I, Evidence A).
• Ipsilateral moderate (50 to 69) carotid
  stenosis, CEA is recommended depending age,
  gender, comorbidities, and the severity of
  symptoms (Class I, Evidence A).
• Stenosis lt 50, there is no indication for CEA
  (Class III, Evidence A).
• Surgery within 2 weeks is suggested rather than
  delaying surgery (Class IIa, Evidence B).

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Carotid Angioplasty and Stenting ASA 2006
Secondary Stroke Recommendations

• CAS may be considered (Class IIb, Evidence B)
• if stenosis (gt70) difficult to access
  surgically,
• for medical conditions that greatly increase the
  risk for surgery, or
• when other circumstances exist such as
  radiation-induced stenosis or restenosis after
  CEA.
• CAS is reasonable when performed by operators
  with morbidity and mortality rates of 4 to 6
  (Class IIa, Evidence B).

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Atrial Fibrillation ASA 2006 Secondary Stroke
Recommendations

• For patients with ischemic stroke or TIA with
  persistent or paroxysmal (intermittent) AF,
  anticoagulation with adjusted-dose warfarin
  (target INR 2.5, range 2.0 to 3.0) is recommended
  (Class I, Evidence A).
• For patients unable to take oral anticoagulants,
  aspirin 325 mg per day is recommended (Class I
  Evidence A).

Albers GW, et al. Chest (2001)119300S-320S.
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Stroke Prevention - Non-cardioembolic ASA 2006
Secondary Stroke Recommendations

• For patients with noncardioembolic ischemic
  stroke or TIA, antiplatelet agents are
  recommended rather than oral anticoagulation to
  reduce the risk of recurrent stroke and other
  cardiovascular events (Class I, Evidence A).

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Stroke Prevention - Non-cardioembolic ASA 2006
Secondary Stroke Recommendations

• Acceptable options for initial therapy (Class
  IIa, Level of Evidence A).
• aspirin (50-325 mg qd)
• the combination of aspirin and extended-release
  dipyridamole (25/200 mg bid)
• clopidogrel (75 mg qd)

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Antiplatelets ASA 2006 Secondary Stroke
Recommendations

• Compared to aspirin alone, both the combination
  of aspirin and extended-release dipyridamole and
  clopidogrel are safe.
• The combination of aspirin and extended-release
  dipyridamole is suggested instead of aspirin
  alone. Class IIa, Level A
• Clopidogrel is suggested instead of aspirin alone
  based on direct comparison trials. Class IIb,
  Level B

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Secondary Stroke Prevention ASA 2006 Secondary
Stroke Recommendations

• Insufficient data are available to make
  evidence-based recommendations regarding choices
  between antiplatelet options other than aspirin.
  Selection of an antiplatelet agent should be
  individualized based on patient risk factor
  profiles, tolerance, and other clinical
  characteristics.

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Secondary Stroke Prevention ASA 2006 Secondary
Stroke Recommendations

• The addition of aspirin to clopidogrel increases
  the risk of hemorrhage and is not routinely
  recommended for stroke or TIA patients. Class
  III, Level A
• For patients allergic to aspirin, clopidogrel is
  recommended. Class IIa, Level B

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Secondary Stroke Prevention ASA 2006 Secondary
Stroke Recommendations

• For patients who have an ischemic cerebrovascular
  event while taking aspirin, there is no reliable
  evidence that increasing the dose of aspirin
  provides additional benefit. Although alternative
  antiplatelet agents are often considered for
  these patients, no single agent or combination
  has been specifically evaluated in patients who
  have had an event while receiving aspirin.

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Stroke and Pregnancy ASA 2006 Secondary Stroke
Recommendations

• For pregnant women with high-risk thromboembolic
  conditions the following options may be
  considered
• adjusted-dose UFH throughout pregnancy,
• adjusted-dose LMWH with Factor Xa monitoring
• UFH or LMWH until week 13, followed by warfarin
  until mid-3rd trimester, then UFH or LMWH in last
  trimester (Class IIb, Evidence C).
• Pregnant women with lower risk conditions may be
  considered for treatment with UFH or LMWH in the
  first trimester followed by low-dose aspirin for
  the remainder of the pregnancy (Class IIb,
  Evidence C).

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Post-menopausal Hormones ASA 2006 Secondary
Stroke Recommendations

• For women with ischemic stroke or TIA,
  postmenopausal hormone therapy (with estrogen
  with or without a progestin) is not recommended
  (Class III, Evidence A).

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Other Circumstances ASA 2006 Secondary Stroke
Recommendations

• Dissections
• PFO and hyperhomocystinemia
• Hypercoagulable states
• Sickle cell disease
• Cerebral venous thrombosis
• Stroke and pregnancy
• Post-menopausal hormone therapy
• Anticoagulation after cerebral hemorrhage